J R Coll Physicians Edinb 2018; 48: 181–91 | doi: 10.4997/JRCPE.2018.214 PAPER

Witnessing history: a personal view of half a century in public health HistoryBP Bergman1, F Laing2, AS Chandler3, KC& Calman4 Humanities Former Chief Medical Of cer Sir recently celebrated 50 Correspondence to: years in medicine. It was a period which saw the evolution of the public BP Bergman Abstract health agenda from communicable diseases to diseases of lifestyle, the Institute of Health and change from a hospital-orientated health service to one dominated by Wellbeing community-based services, and the increasing recognition of inequalities as a Public Health & Health major determinant of health. This paper documents selected highlights from Policy his career including the Aberdeen typhoid outbreak, AIDS, bovine spongiform encephalopathy, 1 Lilybank Gardens foot and mouth disease, radioactive fallout, the invention of computerised tomography and Glasgow G12 8RZ magnetic resonance imaging, and draws parallels between the development of the modern UK understanding of public health and the theoretical background to the science 100 years earlier. Email: Keywords: communicable disease, communities, history, inequalities, public health beverly.bergman@glasgow. ac.uk Declaration of interests: No confl ict of interests declared

Introduction an optimistic speech promising ‘a state of prosperity such as we have never had in my lifetime – nor indeed in the history of There is an iconic phrase which states that if you can this country…most of our people have never had it so good’. remember the Sixties, you were not there.1 An alternative, After the post-Great War austerity of the 1920s and 1930s but untested, hypothesis is that preservation of an intact that may have seemed true, but it was not to hold good for memory of this period may have been occasioned by the future. As early as 1961, Macmillan was forced to impose working in public health. Beginning in the 1960s, this spending cuts and a wage freeze as infl ation began to rise.3 paper examines fi ve decades of developments in public The Sixties had begun. health, focusing on some of the most infl uential events of the period, and was inspired by the 50th anniversary of Outbreaks, epidemics and pandemics had dominated public the graduation in medicine of one of the authors (KCC). It health practice during the 1950s – poliomyelitis, infl uenza, commemorates selected highlights from his career and, and even smallpox. Other serious communicable diseases in so doing, documents a key period of challenges and such as dysentery, infectious hepatitis and measles were transformations, predominantly from a Scottish perspective. so commonplace as to be accepted as a normal part of day It is illustrated by KCC’s personal refl ections. to day life. Although research published in 1950 had clearly demonstrated the link between smoking and lung cancer,4 Historical background the recognition of the importance of lifestyle choices as a determinant of health still lay many years in the future. The end of the Second World War saw Britain emerge The next 50 years were to bring many hitherto unforeseen militarily and politically victorious but at enormous cost to changes, both led by and requiring an agile response by population, economy and infrastructure. Nearly 400,000 public health. service personnel had lost their lives, together with over 65,000 civilians,2 two million homes had been destroyed The Sixties and much damage had been done to ports and industry. Food rationing, introduced in the wake of disruption to The Macmillan speech took no cognisance of the appalling supply lines, continued up until as late as 1954. Rebuilding poverty, overcrowding and living conditions that still of property was slow, and urban bomb sites persisted for characterised many inner cities where the bulk of the working many years as a visual reminder of the destruction, some population was concentrated. Slum clearance was already eventually mutating into car parks. under way, with the slums generally being replaced by high- rise blocks, but the 1961 census showed that 11,000 homes Nonetheless, the post-war global economy proved buoyant and in Glasgow remained unfi t for habitation (Figure 1).5 in 1957 the then Prime Minister, Harold Macmillan, delivered

1Honorary Senior Research Fellow, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK; 2Curator of Offi cial Publications, National Library of Scotland, Edinburgh, UK; 3Doctoral student, 4Chancellor, University of Glasgow, Glasgow, UK

JUNE 2018 VOLUME 48 ISSUE 2 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH 181 BP Bergman, F Laing, AS Chandler et al.

Figure 1 Mother and baby, Glasgow slums, late 1960s. ©Nick Hedges. Reproduced with permission to contaminated corned beef imported from South America, resulted in over 400 cases, but no fatalities. Although the timely public health response is acknowledged to have prevented a much larger outbreak,8 important lessons were learned, especially in relation to the provision of information to the public via the press. A well-intentioned campaign to alert the public to the importance of good personal hygiene, aimed at preventing a possible second wave of infection due to the development of asymptomatic carriers, led to a major over-reaction when places of entertainment were closed, academic staff at the University were advised to wear gloves when handling examination papers and the city became widely known as the ‘Beleaguered City’.9 However, clinical expertise developed at the in the aftermath of that outbreak still continues to inform the The spending cuts and wage freeze led to public disillusionment global management of this disease.10 and industrial unrest, and overall national income declined despite draconian measures aimed at boosting the economy. In 1960, a review of long-term National Assistance The failed US-led Bay of Pigs invasion of Cuba in 1961 was claimants was carried out; foreshadowing concerns about quickly followed by the 1962 Cuban missile crisis, while the number of benefi t claimants 50 years later. Only 6% ongoing nuclear tests in the Pacifi c underlined the continuing were found unfi t for any work although the majority had potential for global nuclear war. Rising levels of strontium-90 some limitation, including mental ill-health in 36% and in milk, as the fallout from the nuclear tests was deposited on gastrointestinal conditions in 12%. Many claimants were calcium-poor soils by Scotland’s high rainfall, led to concerns found employment, or were recommended for admission to about the future health of infants.6 Racial tensions were an industrial rehabilitation unit.11,12 building up worldwide, leading to widespread race riots in the USA in 1967. In the UK, immigration was increasing, The Seventies especially from Africa and the Indian subcontinent, and racial tensions were beginning to emerge here too, culminating in While the 1960s had been the decade of social change, the controversial and damaging speech by Enoch Powell in albeit not always benefi cial, and public health had been 1968. Social unrest grew widely, and was quickly adopted by focused largely on communicable disease and the growing the student population, resulting in mass protests throughout recognition of smoking-related disease, the 1970s were to the summer of 1968. As the decade drew to a close, tensions be dominated by far-reaching organisational reform in the within an increasingly divided erupted into health services and local authorities. The National Health what was to become known as The Troubles. Service (Scotland) Act 1972 repealed and updated much of the original National Health Service (Scotland) Act 1947. It Against that background, societal norms were also changing. set up Health Boards, which remain the foundation of the Divorces rose steadily throughout the 1960s, even before structure of the NHS in Scotland, and established a number the legislative changes brought about by the Divorce Reform of central bodies including the Scottish Health Service Act 1969, leading to a rapid increase in the number of Planning Council and the Common Services Agency (now single parent families and, of necessity, working mothers NHS National Services Scotland), which greatly increased the and ‘latchkey kids’. The stress of coping unsupported by role of management in the NHS. The relationship between a spouse increasingly led to reliance on a new generation the Health Boards and local authorities was set out and, of psychotropic drugs, heavily promoted by industry as a while disestablishing the Medical Offi cer of Health, the Act panacea not only for patients7 but for a medical profession made provision for the appointment of a ‘designated medical facing new challenges from a rising tide of social problems. offi cer’ who would act on behalf of the local authority; this was to become a key role for public health. The post of Health Despite these evolving problems, by the beginning of the Service Commissioner for Scotland was established, to be 1960s, the fall in communicable disease rates since the appointed by The Queen. The Act also provided the legislative Second World War was becoming clear. In Scotland, for framework for the provision of contraceptive services and, example, diphtheria had already fallen from 517 cases in two years later in 1974, free family planning services were 1941 to 54 in 1960, but concerns were being expressed made available to everyone in Scotland, irrespective of age, about rising death rates from lung cancer, coronary heart gender or marital status. disease and chronic bronchitis. The main risk factors had been recognised to be tobacco smoking and air pollution, but At the same time, local government itself was undergoing achieving social change was to prove more of a challenge. major change with the implementation of the Local Typhoid was reported as ‘under control’ with around 15 Government (Scotland) Act 1973, resulting in the replacement cases per year, an assessment which was to prove over- of a structure of counties, burghs and districts which had optimistic when a major outbreak in Aberdeen in 1964, traced largely been in place since the Middle Ages with a two-tier

182 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH VOLUME 48 ISSUE 2 JUNE 2018 Witnessing history: 50 years in public health

Figure 2 Postcard images from the Lothian ‘Take Care’ campaign. system of regional and district councils. Inevitably there were Lothian Health Service Archives. GD22/PD1.4/57 and GD22/ implications for public health at a local level. PD1.4/64, used with permission

The 1972 Act was followed six years later by the National Health Service (Scotland) Act 1978, which fi nally repealed the whole of the 1947 Act. Whereas much of the 1972 Act had been concerned with the management of hospitals, the new Act concentrated on primary care including general practice, dentistry, ophthalmic services and pharmaceutical services, refl ecting an overall shift in focus towards the community. General practice services were to be managed by a Medical Practices Committee established under each Health Board. The Eighties The positive trends in population health which had begun in the 1960s continued. The birth rate continued to fall, The decade opened with the completion of the seminal from 16.8 per 1000 population at the start of the decade report Inequalities in Health, authored by Sir Douglas Black to 12.4 at the end, while stillbirths fell from 14 to 8 and (1913–2002), which highlighted for the fi rst time the excess infant mortality dropped from 20 to 13 per 1000 live births. burden of ill-health and mortality faced by those living in In 1970 there were 59 cases of puerperal fever; by 1975 poverty20 and demonstrated that although overall health had only 6 were recorded. However, annual acute psychiatric improved since the inception of the NHS, there had been no inpatient admissions for alcohol intoxication and alcoholic reduction in social inequalities. The report, commissioned psychosis climbed inexorably from 3000 in 1970 to 5500 in by the Labour government, did not fi nd favour with the newly- 1975 before falling back slightly to 5000 in 1979. Clinical elected Conservative government. Despite its subdued practice was also changing rapidly. As part of a major launch (it was never ‘published’ although photocopies were surgical unit, KCC recalled that each Monday morning and available to the public on request), it went on to make a afternoon was taken up with large peptic ulcer clinics, with major political impact,21 although the need to tackle social pre and post operation options being considered. Within a inequalities, poor housing and unemployment did not receive few years this surgical approach was completely replaced by widespread recognition and political acceptance in the UK drug treatment. Initially this was aimed at reducing gastric until the publication of the subsequent report, Independent acid secretion by blocking the histamine (H2) receptors Inquiry into Inequalities in Health, by Sir Donald Acheson whose role as mediators of acid secretion had been fi rst (1926–2010) 18 years later.22 recognised by Sir James Black in 1971;13 the identifi cation of the proton pump mechanism of gastric parietal cells Meanwhile, a new and ultimately far-reaching communicable in the late 1970s14 paved the way for the addition of disease challenge was on the horizon which would cut across the proton pump inhibitors to this emerging therapeutic the traditional boundaries of socio-economic inequality; armamentarium. However it was the key discovery by Warren AIDS. In 1981, unusual clusters of Pneumocystis carinii and Marshall in 1982 of the microorganism now known as pneumonia and Kaposi’s sarcoma in previously healthy Helicobacter pylori,15 and the subsequent recognition that young men were fi rst reported in the USA, conditions which its eradication could lead to ulcer healing,16 which gave rise were more commonly associated with immunosuppression to the policy that all patients with gastric or duodenal ulcers and older people, and in December of that year, the fi rst case who are infected with H. pylori should receive treatment with was reported in the UK. The AIDS pandemic, as it became, antimicrobial drugs.17 was to become the leading cause of death in adults aged under 60 years, and led to a global public health response During this period, KCC’s special interest was oncology. Over on an unprecedented scale.23 By 1983, the fi rst cases were a 10-year period the ability to diagnose, treat and care for reported in Scotland, among intravenous drug users in patients with cancer changed signifi cantly. New drugs such contrast to the earlier UK cases, particularly in the Greater as the platinum-based antineoplastic agents appeared and London area, which had predominantly affected homosexual revolutionised the management of a number of cancers,18 and bisexual men. The Scottish response was therefore and in particular, testicular tumours.19 Trial and error gave way based initially around needle exchanges and substitution to clinical trials, involving a wide range of clinical staff, and of methadone for injected heroin, with measures aimed at the importance of the team became paramount. The whole the gay community following somewhat later.24 This was process of care was refi ned, putting patients at the heart of followed by a community-wide ‘Take Care’ campaign in 1989 the decision making. Palliative care became recognised as which used a range of promotional materials to highlight a patient-driven specialty, and one which demonstrated the that HIV could affect anyone.25 With the passage of time importance of patient involvement and of communication. and an overall liberalisation of frank speech, it is easy to A patient care group, Tak Tent (‘take care’ in Scots) was underestimate the cultural shift which was required in the established in Scotland and this put the patients fi rmly in the 1980s to overcome the societal taboos surrounding the process of care, representing a 180° shift from the traditional necessary open and public discussion of sexual matters clinician-driven approach. (Figure 2).

JUNE 2018 VOLUME 48 ISSUE 2 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH 183 BP Bergman, F Laing, AS Chandler et al.

In February 1985, a cow on a farm in Sussex died after Chernobyl Nuclear Power Plant near Pripyat, Ukraine. Although developing neurological symptoms and was found at there were few immediate deaths, and only 237 people post-mortem to have a spongiform encephalopathy, a suffered acute radiation sickness, radioactive contamination hitherto unknown cattle disease named bovine spongiform from the disaster affected a very wide area including much of encephalopathy (BSE). It was quickly identifi ed as a prion Russia, Scandinavia and western Europe. Monitoring by the disease and, drawing parallels with known prion diseases National Radiological Protection Board showed that hill areas such as kuru, a ban was imposed on the use of ruminant in Scotland were most affected, notably in the Central belt, proteins in sheep and cattle feed. A Government Working Dumfries and Galloway, Arran, and the Uists. In some areas, Party concluded that it was unlikely to pose a threat to levels of radioactive caesium-137 in sheep meat exceeded humans and that beef remained safe to eat, although in permitted limits for human foodstuffs, and restrictions were the next decade this would prove to have been an over- put in place. As with strontium-90 in the early 1960s, the optimistic assessment. areas most affected were those with high rainfall where the soil mineral content was low. Chernobyl-related monitoring In his book The Potential for Health,26 KCC recalls that three restrictions in Scotland were not fi nally lifted until 2010, 24 important issues were becoming clear. The fi rst was that years after the incident, the last affected farms being in of the potential for health; using the knowledge we have, the East Ayrshire and Stirling areas.30 KCC recalls that at it should be possible to improve health. Issues such as the time, he was an adviser to the Dounreay Nuclear Power smoking, alcohol and obesity were just three of the most Station enquiry, which was investigating the safety of the obvious factors, in turn inextricably linked to the major process. He spotted a whole body radioactive counter and problem of inequalities in health which still exist. The second decided to test the process on himself. Having recently been issue was that of akrasia, the ability to know that something on the island of Arran he was alarmed to fi nd that his body is wrong, but still doing it. How do we get people to change had a measurable level of caesium-137 although, almost 30 behaviour? The fi nal issue was that of risk, its recognition, years on, he reports no adverse effects! communication and the language used to discuss it.27 For each of these issues, telling the right story at the right time At the start of the decade, there had been early evidence that can certainly help, but there still remains a need to get much both the incidence and the death rate from coronary heart better at doing it. disease, which had been rising steadily since the 1950s, had stabilised or possibly begun to fall, and by the end of The second half of the 20th century saw major advances the decade it was clear it was indeed falling. Only part of the in medical imaging which, in turn, were to revolutionise trend in mortality could later be explained by improvements in non-invasive diagnosis. Although the principles of X-ray the management of cardiovascular disease.31 But admissions tomography had been known for some time, it was the to acute hospitals for alcohol-related conditions including advances in computing power in the 1960s which paved the liver disease were now beginning to increase, in contrast to way for the development of computerised tomography (CT) the reduction in admissions to mental hospitals for acute and for the fi rst commercial CT scanner, the EMI-Scanner, in intoxication and psychosis which continued to fall, continuing 1971. However CT scanning involves exposure to substantial a trend observed throughout the previous decade and radiation doses, and the development of magnetic resonance suggesting that the longer-term impact of alcohol misuse imaging (MRI) in the 1970s represented a major advance in was now becoming manifest. patient safety. The world’s fi rst full-body MRI scanner was developed at the University of Aberdeen and the fi rst clinical There were two further important developments in the scan on a living patient was performed on 28 August 1980. 1980s. The fi rst concerns the emergence of medical ethics The prototype scanner has now been refurbished and is as a recognised discipline. This was partly due to a greater displayed at Aberdeen Royal Infi rmary where it forms part of recognition of the practical implications of advances in the University Museums’ collection.28 treatment and investigations. The issue of communication was central to this. Related to this was the importance of During the 1980s there were several major industrial the teaching and learning in medicine about ethical issues. accidents on the international stage, of which some had This had been a bedside issue in the past, at the discretion implications for public health in the UK. In 1984, an explosion of individual clinical teachers, but formal courses were now at the Union Carbide India Limited pesticide plant in Bhopal, becoming established.32 India, led to a major release of methyl isocyanate and an estimated initial death toll of nearly 4000, with over half The second development was that related to the arts a million injuries. Since then, a further 8000 people are and humanities in clinical and public health practice. This estimated to have died from the effects of the incident, and involved, at fi rst, the use of literature in the teaching of many thousands have been left permanently disabled. A medical students, but has since developed to encompass large-scale cohort study has been in progress since then to dance, theatre, moving images and music. There have been follow up the survivors; methodological shortcomings in that a number of resources developed for the arts including the study have led to the identifi cation of important lessons for book Tools of the Trade from the Scottish Poetry Library, which the epidemiological follow-up of major incidents.29 Eighteen is now distributed to all new medical graduates in Scotland,33 months later, a catastrophic nuclear accident occurred at the and KCC’s own comprehensive review of 700 years of Scottish

184 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH VOLUME 48 ISSUE 2 JUNE 2018 Witnessing history: 50 years in public health

Figure 3 Birth and death rates per 1000 population, Scotland medicine as seen through contemporary Scottish literature, ‘A 1960-2016. Contains public sector information licensed under the Doctor’s Line’: Poetry and Prescriptions in Health and Healing.34 Open Government Licence v3.0 More recently, the critically-acclaimed dance performance 5 Soldiers has brought an understanding of the issues faced by physically and psychologically injured veterans to a wide audience,35 further illustrating the importance of the arts as a medium for health communication. The Nineties

As the second millennium entered its last decade, the shape of Scotland’s population was becoming dominated by older people. In 1991, the number of people aged over 90 now equated to the number who had been aged over 75 just 30 years earlier, despite no change in the overall size of the population. The number of over-90s was to almost double again in the next 20 years, by which time the number of people aged over 65 exceeded the number aged under 15, the low birth rate of 11 per 1000 population at the end of the 1990s refl ecting a trend of reducing numbers of children the game and pre-empt that diversion is always a good ploy, per family throughout the preceding 100 years, with major as described by KCC in A Study of Storytelling, Humour and implications for the dependency ratio underpinning support Learning in Medicine.40 The power of the media to infl uence for the elderly. The very rapid fall during the 1960s may public opinion and behaviour was to be well illustrated by the have refl ected increasing uptake of the oral contraceptive 1998 ‘vaccine scare’. pill. By the end of the decade, the birth rate had fallen below the death rate (Figure 3), resulting in a net reduction Ever since the anti-vaccination movement graphically in the population, although in subsequent years increasing portrayed by the cartoonist James Gillray in 1802,41 such immigration was to offset the fall. The rising numbers of scares have threatened the widespread uptake of vaccines older people brought an increasing burden of dementia, necessary to achieve herd immunity. In the 1970s, media contributing to care needs, with over 30% of the over-90s reports of neurological reactions to the widely-used pertussis estimated to be affected.36 component of the ‘triple’ DTP vaccine had led to a rapid decline in coverage, from 77% to 33% or lower, and three During the early part of the decade, evidence began to major epidemics of pertussis ensued, the fi rst affecting accumulate that BSE was transmissible not only from cow to over 100,000 people. Although a government compensation cow but also between species. In 1995 the fi rst human death scheme for alleged vaccine damage was established, the from variant Creutzfeldt-Jakob disease (vCJD) was reported, aetiological role of the vaccine remained controversial and and in 1996 the Spongiform Encephalopathy Advisory the eventual legal judgement in 1988 was that there was Committee, which had previously issued reassurances that no evidence it caused permanent neurological sequelae.42 transmission to humans was unlikely, announced there was Nonetheless, both media commentators and the public were a probable link between BSE and vCJD. The National CJD by now well-rehearsed in the arguments against vaccination Research and Surveillance Unit was established at the when the fi res were re-ignited by the publication in The Lancet University of Edinburgh to monitor the characteristics of the in 1998 of a paper by Andrew Wakefi eld, later discredited disease, identify trends, study risk factors and improve care and retracted in full, claiming to have demonstrated a link of those affected, with close links to a wide range of other between the measles, mumps and rubella (MMR) vaccination, UK agencies. The initially alarming predictions of a major inflammatory bowel disease and autism.43 Predictably, epidemic have proved unfounded to date; the peak year of MMR vaccination coverage fell (Figure 4) and there was a onset was 1999, with 29 cases, and no UK cases have been resurgence in incidence of all three diseases, especially reported in people born after 1989. Of the 178 UK cases of mumps (Figure 5). It was some 10 years before coverage vCJD, 24 have been in those resident in Scotland, of whom rates returned to ‘pre-Wakefi eld’ levels, and a substantial the majority have been in the west.37 cohort of children never received the vaccine. Fortunately, despite these children having now reached childbearing age, These incidents demonstrated a further factor in improving there has been no evidence of a resurgence of congenital public health; the media. While a free press is highly valued rubella syndrome.44 in democratic societies,38 there is also a commercial element that may lead to distortion of coverage,39 which in turn may Another aspect of the improvement of health is in the impact on the accuracy of scientifi c reporting. Although in development of policy at government level, and the general terms the media are a force for good in telling stories implementation of the resulting written reports. Those of of health and illness, it is important to always remember that particular interest in KCC’s career were Hospital Doctors: the ‘good story’ is the main driver and that to be ahead of Training for the Future,45 A Policy Framework for Commissioning

JUNE 2018 VOLUME 48 ISSUE 2 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH 185 BP Bergman, F Laing, AS Chandler et al.

Figure 4 Vaccine coverage rates in Scotland 1995-2016.78 ©Health Protection Scotland 2017. Contains public sector information licensed under the Open Government Licence v3.0

Figure 5 Mumps in Scotland 1989-2013.79 ©Health Protection Scotland 2013. Contains public sector information licensed under the Open Government Licence v3.0

Cancer Services,46 and Developing Emergency Services in the The new millennium Community.47 These were all implemented but could not have been achieved without the cooperation and full input from the With the benefi t of hindsight, it is easy to overlook the level of medical royal colleges and postgraduate deans. Patients were health service resources which were devoted to preparations also involved in two of these policy areas and contributed for the predicted impending ‘millennium bug’, a computer signifi cantly. One of these, on Cancer Services, took time problem resulting from early programming use of a two-digit to implement because its issue coincided with a period of year date format which, it was predicted, would result in change in the NHS itself. systems rolling back to a notional ‘year 1900’ at the turn of the millennium and would lead to widespread disruption. This raises the issue of how best to implement major new The fears proved to be largely unfounded, although one of policies. Four things seem to matter. The fi rst is that there the few serious healthcare-related incidents occurred in needs to be signifi cant political will to make it happen. Sheffi eld where incorrect Down’s syndrome test results were The second is to have a clear and agreed strategy. There sent to 154 women as a result of incorrect calculation of the then needs to be people on the ground to implement the mother’s age. Two inappropriate terminations were carried policy. This is a key aspect of the process and the changes out, and four affected babies were born after their mothers in postgraduate medical education could not have occurred had been informed that they were low-risk.48 without effective local input. The fi nal strand is the resources required to take things forward. This could be fi nance, but Epizootic diseases continued their dominance, with a major could also include people and buildings. In looking back at UK-wide outbreak of foot and mouth disease in 2001 which policy implementations, and cross referencing them to these led to the slaughter of over 10 million sheep and cows. four factors, it is usually possible to determine why the policy Movement of farm animals was restricted, as was access has been implemented successfully or, conversely, failed. to the countryside, and all animal carcases in the vicinity of affected farms were burned, an operation which required the

186 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH VOLUME 48 ISSUE 2 JUNE 2018 Witnessing history: 50 years in public health

Figure 6 Alcohol-related morbidity and mortality in Scotland 1961-2015. Compiled from various archive sources. Contains public sector information licensed under the Open Government Licence v3.0

assistance of the Army. The outbreak left a legacy of both cases and 11,310 deaths.59 Novel diseases continued to economic and emotional damage,49 while several soldiers emerge, while others changed their character. A large cluster involved in carcase disposal contracted Q fever.50 With of cases of microcephaly in Brazil in 2015–2016 marked hindsight, while the disease was managed in accordance the evolution of Zika virus, known for over 60 years as a with extant protocols, there was a failure to fully appreciate mild mosquito-borne disease, to a condition having profound the psychological effect on those involved,51 not only among implications for pregnant women and their fetuses. Cases the affected farmers but also those who took part in the associated with Guillain-Barré syndrome were also identifi ed, cull. Although psychological impact was noted in the Scottish both in Brazil and in an outbreak in French Polynesia, and Government response and funding was made available for global spread of the virus was reported, causing considerable local counselling, there was no mention in the ‘lessons anxiety to travellers. learned’ of any requirement to include specifi c support in future plans.52 Continuing the epizootic theme, in 2000 the Sixty-fi ve years on from the publication of the fi rst conclusive fi rst case of anthrax in an injecting drug user was reported evidence of the link between smoking and lung cancer,4 from Norway,53 and in 2009–2010 a serious outbreak Scotland led the way for a UK-wide ban on smoking in occurred among the drug-using population of Scotland, indoor public places with the publication of an Act of the ultimately involving 82 confi rmed or probable cases.54 The Scottish Parliament,60 which came into force on 26 March source was postulated to have been a contaminated goat or 2006. By now, the case against smoking was compelling; other animal hide used to transport a batch of heroin between in 2004 Richard Doll had published a 50-year follow-up on Afghanistan or Pakistan and Scotland.55 his original study of doctors’ mortality in relation to smoking which showed that on average, smokers died 10 years earlier In the global arena, 2009 saw the fi rst infl uenza pandemic than non-smokers and had up to a three-fold increase in the since 1968–1969. Nicknamed ‘swine fl u’ in recognition of risk of dying in middle age.61 The benefi cial impact of the its origin as a re-assortment of bird, swine and human fl u ban on acute coronary events quickly became apparent;62 viruses, its antigenic similarity to the 1918 pandemic virus the benefi ts to lung cancer incidence and mortality will take led to widespread alarm, not entirely unjustifi ably in view longer to realise. The Scottish Government’s tobacco control of the estimated 284,500 fatalities worldwide.56 The public strategy was published in 2013 and set an ambitious target health response in Scotland was swift, moving from an initial to reduce smoking prevalence in Scotland to 5% or less in 20 containment phase to a treatment phase as cases became years.63,64 Although the overall prevalence of adult smoking in more widespread, with an immunisation programme being Scotland had fallen to 21% by 2015, major challenges remain rolled out as a specifi c vaccine became available. Over 1500 in the lower socio-economic groups, with the prevalence people were hospitalised in Scotland, including 54 pregnant ranging from 35% in the most deprived communities, to 11% women, and there were 69 deaths including three pregnant in the least deprived.65 women.57 Several patients required extracorporeal membrane oxygenation for profound respiratory failure.58 Drug and alcohol problems continued unabated. Admissions and deaths due to alcohol-related conditions rose to a peak Communicable disease challenges continued to dominate around 2005–2007 and have since fallen back, perhaps a public health as the new millennium progressed. The highly late legacy of very heavy drinking some 30 years earlier, while transmissible Ebola virus, which had fi rst been identifi ed in liver disease has plateaued, possibly refl ecting an overlap 1976 and had been causing sporadic outbreaks in Africa, from the growing number of cases of obesity-related liver now gave rise to the largest-ever outbreak which ran from disease (Figure 6).66 Drug-related deaths in Scotland rose 2013–2016 in West Africa, resulting in a reported 28,616 from an annual average of 260 in 1996–2000 to 659 in

JUNE 2018 VOLUME 48 ISSUE 2 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH 187 BP Bergman, F Laing, AS Chandler et al.

Figure 7 Life expectancy at birth, Scotland 1960-2012.80 Contains public sector information licensed under the Open Government costs. A framework for action was proposed to improve Licence v3.0 health and wellbeing for all and reduce inequalities, based on a wide-ranging portfolio of priority objectives and policy recommendations extending across the spectrum of national, local and third sector involvement. Crucially, the review identifi ed the major threats to health as smoking, alcohol, obesity and drug use, and the major social determinants of health as the early years, education, work, income, and communities.

Five years later, a report by the King’s Fund72 painted a more optimistic picture. Analysing data from 2006–2010, in comparison with 1999–2003, there was clear evidence that income-related inequalities had improved since Marmot’s ‘call to action’, with a fl attening of the gradient. The report also noted geographical variations, with some 2012–2016, but with a shift towards the older age-groups; parts of the UK doing better than the average, while others the average of 83 per year for under-25s in 1996–2000 experienced poorer outcomes, highlighting the importance of fell to 39 per year in 2012–2016, while for the 35–44 age taking local knowledge, history and experience into account group, the number rose from 46 per year to 234 over the when translating strategy into action. The King’s Fund had same period,67 also suggesting legacy problems affecting previously identifi ed that a lack of community and networks long-term drug users. Comparison with earlier years (1995 was more damaging to the health of older people than either and earlier) is problematic owing to changes in coding and moderate smoking or obesity;73 now there was clear evidence the method of recording.68 that communities could be a powerful force in infl uencing health behaviours, and hence addressing inequalities. In Obesity was identifi ed as a major emerging public health Scotland, this work was being taken forward by a Ministerial problem, in Scotland as elsewhere in the developed world, Task Force as the Equally Well policy,70 and delivered through with the proportion of people aged 16–64 recorded as a network of Community Planning Partnerships. overweight (BMI 25 and over) increasing from 52% in 1995 to 62% in 2015. The proportion recorded as obese (BMI 30 Conclusion and over) rose from 17% to 28% over the same period, while the proportion of morbidly obese (BMI 40 and over) rose from From these selected personal highlights of half a century 1% to 3%. The greatest numbers of obese men in 2015 were in medicine, a number of themes have emerged. There in the 55–64 age group (40%), whereas for women it was have been known diseases which have occurred on an 45–54 (34%). A raised waist circumference was recorded unprecedented scale, for example the 1964 Aberdeen typhoid in 34% of men aged 16–64 in 2015, compared with 14% in and the 2001 foot and mouth disease outbreaks, where 1995, while for women it was 48% in 2015 compared with the protocols for management were well established and a 19% in 1995. By the end of the 10 years to 2015, 52% of timely response was put in place to cope with the scale and men were identifi ed as being at increased health risk based severity of the problem although, with the benefi t of hindsight, on BMI and waist circumference, compared with 19% at the aspects such as media involvement or psychological support start of the period; for women, the proportion had increased could have been better managed. Greater challenges have from 40% to 66%. However the proportion of children outwith been presented by newly-recognised conditions such as the healthy range has been falling since 2011, providing HIV and BSE, where an understanding of the disease, its guarded optimism that the peak may have passed.69 On a epidemiology and, most importantly, its prevention, has positive note, life expectancy has continued to rise, although emerged only slowly, giving rise to a perception of the delivery at a slower rate than some European countries,70 and there of mixed messages to the public. Although unavoidable, this was evidence that the gap between men and women was uncertainty and changes in advice are poorly understood by starting to narrow (Figure 7). the target audience, and the role of public health in managing the public-facing response to any major incident is crucial. Thirty years on from Sir Douglas Black’s report, Sir presented a further review of inequalities and health There have been a number of major transitions, from a in .71 This painted a dismal picture of the premature largely hospital-based care system to one in which care loss of up to 2.5 million years of life, and 2.8 million years of in the community predominates, and from communicable limiting illness or disability, as a result of health inequalities diseases amenable to public health solutions to the diseases stemming from social inequalities. There were major of lifestyle which will require individual behavioural change geographical disparities, with the greatest impact falling to address; the falls in perinatal mortality and childhood in the north-east, especially in the lowest socio-economic morbidity of the 1960s may yet prove to be counterbalanced groups. The cost to society was estimated at up to £70 by rising lifestyle-related morbidity in the same generation. billion per year in lost productivity, welfare and healthcare These changes have taken place against a background

188 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH VOLUME 48 ISSUE 2 JUNE 2018 Witnessing history: 50 years in public health

of rapid technological evolution which has seen, at a the individual military units, supported by embedded specially clinical level, the development of high-quality non-invasive trained staff, who could work with the knowledge of local diagnostic procedures such as MRI, and at a population issues to enable local solutions to be developed based on level, an increase in both the speed and pervasiveness the ‘art of the possible’. One hundred years later, there is a of communication and increasing critical scrutiny and clear parallel with the development of an understanding of accountability of every aspect of public life, combined inequalities, progressing from a recognition of the issues,20,22 with budgetary constraints. While undoubtedly driving up to a clear understanding of the strategy that would be needed standards, this has created new pressures for the health to achieve change,71 and to acknowledgement that central professions and the challenge for the next generation will be strategy is at its most effective when translated into local to maintain an environment in which innovation in healthcare delivery through community engagement.73 Only then can and health protection can still fl ourish. local barriers to change be overcome to enable the ‘art of the possible’ and move towards the ultimate goal of public This year marks the centenary of the end of the First World War, health, Salus populi suprema lex esto.77 a confl ict which cost over 750,000 British lives. In contrast to the Crimean War 60 years earlier, when an estimated 16,000 It is clear that overall health has improved over the last 50 (73%) of the 22,000 deaths had been the result of largely years. However, there is much still to do and the objectives preventable disease, only 19% of deaths in the First World are obvious. A reduction in cigarette smoking, alcohol War were due to illness,74 despite the extremely austere consumption and the use of illegal drugs, are ongoing issues. conditions prevailing in theatres such as the Western Front Obesity has now become a major threat to public health and Gallipoli. The turning point had been the advancement and needs urgent attention. At the heart of this are the from the late 19th century theoretical formulation of the remaining inequalities in health which have shifted a little science of ‘hygiene’, being an understanding of the physical but still remain a major health issue. Let us hope that the effect of the environment on populations,75 to the early 20th next 50 years will see a signifi cant change in this aspect of century practical application of ‘sanitary science’, which the health of the nation. refl ected the art of accommodating to the surroundings,76 Acknowledgements however challenging or austere those may be. Although overarching health strategy could be developed centrally, it was The authors gratefully acknowledge the support for this project recognised that its implementation could only be achieved by shown by the copyright holders cited in the image captions.

References 1 Christon L. The Comedy Column: Shandling Takes the Low-Key 13 Black J, Duncan W, Durant CJ et al. Definition and antagonism of Road. Los Angeles Times 13 June 1982. histamine H2-receptors. Nature 1972; 236: 385–90. 2 Commonwealth War Graves Commission. Commonwealth War 14 Forte J, Lee H. Gastric adenosine triphosphatases: a review of their Graves Commission Annual Report 2014–15; 2015. possible role in HCl secretion. Gastroenterology 1977; 73: 921–6. 3 University of Leeds. The British Political Scene in the 1960s. 15 Marshall B, Warren JR. Unidentified curved bacilli in the stomach of http://www.leeds.ac.uk/politics/cbl/brit/scene.htm (accessed patients with gastritis and peptic ulceration. Lancet 1984; 323: 6/9/17). 1311–5. 4 Doll R, Hill AB. Smoking and carcinoma of the lung. Brit Med J 16 Borody T, Cole P, Noonan S et al. Recurrence of duodenal ulcer and 1950; 2: 739. Campylobacter pylori infection after eradication. Med J Australia 5 Shelter Scotland. Scotland’s Housing Crisis. http://www. 1989; 151: 431–5. scotlandhousingcrisis.org.uk (accessed 6/9/17). 17 National Institutes of Health. Helicobacter Pylori in Peptic Ulcer 6 Scottish Home and Health Department. Health and Welfare Disease. Consensus Development Conference Statement. 7–9 Services in Scotland. Report for 1966 (Cmd 2984). 1966, February 1994. https://consensus.nih. Edinburgh, HMSO. gov/1994/1994HelicobacterPyloriUlcer094html.htm (accessed 7 The Rolling Stones. ‘Mother needs something today to calm her 23/1/18). down/And though she’s not really ill/There’s a little yellow pill/She 18 Lebwohl D, Canetta R. Clinical development of platinum complexes goes running for the shelter of a mother’s little helper/And it helps in cancer therapy: an historical perspective and an update. Eur J her on her way, gets her through her busy day’. ©1966 Abkco Cancer 1998; 34: 1522–34. Music, Inc. 19 Einhorn LH. Testicular Cancer as a Model for a Curable Neoplasm; 8 Scottish Home and Health Department. The Aberdeen typhoid The Richard and Hinda Rosenthal Foundation Award Lecture. outbreak 1964. Report of the departmental committee of enquiry. Cancer Res 1981; 41: 3275–80. (Cmnd. 2542) 1964, Edinburgh, HMSO. 20 Gray AM. Inequalities in health. The Black Report: a summary and 9 Pennington H. Have Bacteria Won? Cambridge: Polity Press; 2016. comment. Int J Health Serv 1982; 12: 349–80. 10 University of Aberdeen. Typhoid 50 years on: Pioneering research 21 Obituary: Sir Douglas Black. BMJ 2002; 325: 661. into cure for global killer. https://www.abdn.ac.uk/news/6273 22 Bambra C, Smith KE, Garthwaite K et al. A labour of Sisyphus? (accessed 6/9/17). Public policy and health inequalities research from the Black and 11 Department of Health for Scotland. Report of the Department of Acheson Reports to the Marmot Review. J Epidemiol Community Health for Scotland 1960. Part I: Health and Welfare Services Health 2011; 65: 399–406. (Cmnd 1320) 1961, Edinburgh, HMSO. 23 Merson MH. The HIV–AIDS pandemic at 25 – the global response. 12 Vaughan Jones JAL. Back to work. Brit Med J 1951: 2: 601–3. N Eng J Med 2006; 354: 2414–7.

JUNE 2018 VOLUME 48 ISSUE 2 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH 189 BP Bergman, F Laing, AS Chandler et al.

24 HIV Scotland. History: How HIV has changed. http://www. 51 Peck DF, Grant S, McArthur W et al. Psychological impact of foot- hivscotland.com/about-us/history (accessed 9/8/17). and-mouth on farmers. J Ment Health 2009; 11: 523–31. 25 University of Edinburgh Social Studies. The ‘Take Care’ Campaign 52 Scottish Executive. Foot and Mouth Disease in Scotland – The Report. http://hiv-aids-resources.is.ed.ac.uk/wp-content/ Scottish Executive Response. Edinburgh, 2002. http://www.gov. uploads/2015/03/SOC2.Take_Care_Campaign_Report.pdf scot/Publications/2005/01/20602/51164 (accessed (accessed 9/8/17). 12/4/18). 26 Calman KC. The Potential for Health. Oxford: Oxford University 53 Ringertz SH, Høiby EA, Jensenius M et al. Injectional anthrax in a Press; 1998. heroin skin-popper. Lancet 2000; 356: 1574–5. 27 Bennet P, Calman KC. Curtis S et al. Risk Communication and Public 54 Palmateer NE, Ramsay CN, Browning L et al. Anthrax infection Health. Oxford: Oxford University Press; 1999. among heroin users in Scotland during 2009–2010: a case- 28 University of Aberdeen. Medical Library News: World’s first MRI control study by linkage to a national drug treatment database. scanner now on display. https://aberdeenmedlib.wordpress. Clin Infect Dis 2012; 55: 706–10. com/2016/03/21/worlds-first-mri-scanner-now-on-display 55 Scottish Drugs Forum. Anthrax. http://www.sdf.org.uk/what-we- (accessed 9/8/17). do/reducing-harm/infection-outbreak-control/anthrax (accessed 29 Sharma DC. Bhopal study represents ‘missed opportunity’. Lancet 16/8/17). 2013; 382: 1870. 56 Dawood FS, Iuliano AD, Reed C et al. Estimated global mortality 30 Scottish Government. Chernobyl and its effect on Scottish associated with the first 12 months of 2009 pandemic influenza Agriculture. http://www.gov.scot/Topics/farmingrural/Agriculture/ A H1N1 virus circulation: a modelling study. Lancet Infect Dis Livestock/Meat/Sheep/chernobyl (accessed 9/8/17). 2012; 12: 687–95. 31 Hotchkiss JW, Davies CA, Dundas R et al. Explaining trends in 57 Health Protection Scotland. The Pandemic of Influenza A(H1N1) Scottish coronary heart disease mortality between 2000 and 2010 Infection in Scotland 2009-2010: A Report on the Health using IMPACTSEC model: retrospective analysis using routine data. Protection Response. 2010. http://www.hps.scot.nhs.uk/ BMJ 2014; 348: g1088. resourcedocument.aspx?resourceid=901 (accessed 12/4/18). 32 Downie RS, Calman KC. Health Respect: Ethics in Health Care. 58 Berryman S. Extracorporeal membrane oxygenation in a Scottish Oxford: Oxford University Press; 1994. intensive care unit. Nurs Crit Care 2010; 15: 262–8. 33 Gillies J, Morrison L, Newell A et al. Tools of the Trade: Poems for 59 Meltzer MI, Atkins CY, Santibanez S et al. Estimating the future New Doctors. Scottish Poetry Library, 2016. number of cases in the Ebola epidemic—Liberia and Sierra Leone, 34 Calman KC, ‘A Doctor’s Line’: Poetry and Prescriptions in Health and 2014–2015. MMWR Suppl 2014; 63(Suppl 3): 1–14. Healing. Dingwall: Sandstone Press; 2014. 60 Smoking, Health and Social Care (Scotland) Act 2005 (2005 asp 35 5 Soldiers. http://www.5soldiers.co.uk (accessed 29/11/17). 13). 36 Wilson G, Fearnley K. The Dementia Epidemic. Edinburgh: Alzheimer 61 Doll R, Peto R, Boreham J et al. Mortality in relation to smoking: Scotland; 2007. 50 years’ observations on male British doctors. BMJ 2004; 328: 37 National CJD Research & Surveillance Unit. Creutzfeldt-Jakob 1519. disease surveillance in the UK: 24th Annual Report 2015. https:// 62 Mackay DF, Irfan MO, Haw S et al. Meta-analysis of the effect of www.cjd.ed.ac.uk/sites/default/files/report24.pdf (accessed comprehensive smoke-free legislation on acute coronary events. 12/4/18). Heart 2010; 96: 1525–30. 38 Brunetti A, Weder B. A free press is bad news for corruption. J 63 Scottish Government. Creating a Tobacco-Free Generation: A Public Econ 2003; 87: 1801–24. Tobacco Control Strategy for Scotland. 2013. http://www.gov. 39 Ellman M, German F. What do the papers sell? A model of scot/resource/0041/00417331.pdf (accessed 12/4/18). advertising and media bias. Econ J 2009; 119: 680–704. 64 Scottish Government. Smoking. October 2017. http://www.gov. 40 Calman KC. A Study of Story Telling, Humour and Learning in scot/Topics/Statistics/Browse/Health/TrendSmoking (accessed Medicine. Stationery Office Books; 2000. 6/9/17). 41 British Museum. The Cow-Pock or the Wonderful Effects of the New 65 Scottish Health Survey 2015 data. Tobacco use: adult smoking in Inoculation. http://www.britishmuseum.org/research/collection_ Scotland. http://www.scotpho.org.uk/behaviour/tobacco-use/ online/collection_object_details.aspx?objectId=1638225&partId= data/adult-smoking-in-scotland (accessed 6/9/17). 1&people=18459&peoA=18459-1-7&page=1 (accessed 66 Diehl AM, Goodman Z, Ishak KG. Alcohollike liver disease in 16/8/17). nonalcoholics: a clinical and histologic comparison with alcohol- 42 Baker JP. The pertussis vaccine controversy in Great Britain, 1974– induced liver injury. Gastroenterology 1988; 95: 1056–62. 1986. Vaccine 2003; 21: 4003–10. 67 National Records of Scotland Drug-related Deaths in Scotland in 43 Wakefield AJ, Murch SH, Anthony A et al. RETRACTED: Ileal- 2016. https://www.nrscotland.gov.uk/statistics-and-data/ lymphoid-nodular hyperplasia, non-specific colitis, and pervasive statistics/statistics-by-theme/vital-events/deaths/drug-related- developmental disorder in children. Lancet 1998; 351: 637–41. deaths-in-scotland/2016/list-of-tables-and-figures (accessed 44 Tookey P. Congenital rubella. British Paediatric Surveillance Unit 16/8/17). 24th Annual Report 2009–2010. Department of Health/Royal 68 National Records of Scotland Figures for drug-related deaths for College of Paediatrics and Child Health. London 2010. https:// Scotland for 1995 and earlier years. https://www.nrscotland.gov. www.rcpch.ac.uk/system/files/protected/page/Annual%20 uk/files//statistics/drug-related-deaths/drd14/figures-for-drug- Report%200910.pdf (accessed 12/4/18). related-deaths-1995-and-earlier-years.pdf (accessed 16/8/17). 45 Department of Health. Hospital Doctors: Training for the Future; the 69 Scottish Government. The Scottish Health Survey 2015 – Obesity. Report of the Working Group on Specialist Medical Training. Health http://www.gov.scot/Publications/2016/09/2764/ Publications Unit, Heywood, Lancs, 1993. downloads#res505810 (accessed 16/8/17). 46 Expert Advisory Group on Cancer. A policy framework for 70 Scottish Government. Equally Well Review 2013. Scottish commissioning cancer services: A report by the Expert Advisory Government. Edinburgh 2014. Group on Cancer to the Chief Medical Officers of England and 71 Marmot MG, Allen J, Goldblatt P et al. Fair society, healthy lives: Wales. London: Department of Health; 1995. Strategic review of health inequalities in England post-2010. The 47 Calman KC. Developing Emergency Services in the Community: the Marmot Review. 2010. https://www.parliament.uk/documents/ Final Report. NHS Executive, 1997. fair-society-healthy-lives-full-report.pdf (accessed 12/4/18). 48 Wainwright M. NHS faces huge damages bill after millennium bug 72 Buck D, Maguire D. Inequalities in life expectancy. Changes over error’. The Guardian 14 September 2001. https://www.theguardian. Time and Implications for Policy. King’s Fund; 2015. https://www. com/uk/2001/sep/14/martinwainwright (accessed 12/4/18). kingsfund.org.uk/sites/default/files/field/field_publication_file/ 49 Convery I, Mort M, Baxter J et al. Animal Disease and Human inequalities-in-life-expectancy-kings-fund-aug15.pdf (accessed Trauma: Emotional Geographies of Disaster. Basingstoke: Palgrave 12/4/18). Macmillan; 2008. 73 Buck D, Gregory S. Improving the public’s health: a resource for 50 Kelly DJ, Richards AL, Temenak J et al. The past and present threat local authorities. The King’s Fund; 2013. https://www.kingsfund. of rickettsial diseases to military medicine and international public org.uk/sites/default/files/field/field_publication_file/improving- health. Clin Infect Dis 2002; 34(Supp 4): S145–69. the-publics-health-kingsfund-dec13.pdf (accessed 12/4/18).

190 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH VOLUME 48 ISSUE 2 JUNE 2018 Witnessing history: 50 years in public health

74 Macpherson WG. Official Medical History of the War: Casualties and 79 Health Protection Scotland. Mumps. http://www.hps.scot.nhs.uk/ Medical Statistics. London: HMSO; 1931. publichealthact/annualdata.aspx#tables&charts (accessed 75 Parkes EA. A Manual of Practical Hygiene. London: Churchill; 1864. 12/4/18). 76 Melville CH. Military Hygiene and Sanitation. London: Edward 80 Based on National Records of Scotland data. Life Expectancy at Arnold; 1912. Scotland Level – Scottish National Life Tables. https://www. 77 Cicero MT. ‘The health of the people shall be the highest law’. De nrscotland.gov.uk/statistics-and-data/statistics/statistics-by- Legibus vol.III part III sub.VIII. theme/life-expectancy/life-expectancy-at-scotland-level/scottish- 78 Health Protection Scotland Weekly Report. 10 January 2017. national-life-tables (accessed 29/8/17). http://www.hps.scot.nhs.uk/immvax/wrdetail. aspx?id=71753&wrtype=9 (accessed 12/4/18).

In memoriam In memoriam brings to the attention of Fellows and Fellows and Collegiate Members are invited to provide the Collegiate Members the deaths of colleagues and friends. College ([email protected]) with information that will Obituaries paying tribute to the life and work of those whose enable us to write obituaries. Self-written obituaries to be deaths have been reported in In memoriam can be found on held in readiness will always be welcome. the College website: www.rcpe.ac.uk/obituaries

Dr F M Baber FRCP Edin Dr W D Masson FRCP Edin Born: 15/11/1925 Born: 26/09/1931 Died: 17/03/2018 Specialty: Paediatrics/Community Child Health Specialty: Paediatrics/Community Child Health MB Manc 1950, DCH Lond 1954, MRCP Edin 1957 MB Aberd 1955, DCH Glasg 1964, DTM&H Lond 1963, MRCP Edin 1969 Dr D Bell FRCP Edin Born: 21/05/1942 Died: 17/04/2018 Dr G C Schild FRCP Edin Specialty: Public/Community Health/Epidemiology Born: 28/11/1935 Died: 03/08/2017 BSc Durham 1963, MB Durham 1966, MSc Edin 1979, CDAS Specialty: Medical Microbiology/Bacteriology/Virology Stirl 1998 BSc Reading 1958, PhD Sheff 1963, DSc Reading 1994

Dr C N Deivanayagam FRCP Edin Dr D J Sinclair FRCP Edin Born: 15/11/1942 Died: 20/11/2012 Born: 09/04/1933 Died: 05/04/2018 Specialty: Respiratory Specialty: Radiology MB Madras 1966, MRCP Edin 1969 Resp Dis & Tub MB Edin 1957, DMRD Edin 1963, MRCP Edin 1965 Radiodiag

Dr H K El-Shamy FRCP Edin Dr Dr M K Strelling FRCP Edin Born: 31/05/1930 Died: 22/03/2018 Born: 18/03/1925 Died: 16/02/2018 Specialty: Dermatology Specialty: Paediatrics/Community Child Health MB Ain Shams 1954, DV&D Ain Shams 1957, MRCP Edin MB Lond 1953, DCH Lond 1957, DObstRCOG Lond 1957, 1962, LMSSA Lond 1963 MRCP Edin 1963 Child Life

Dr M W M Hadley FRCP Edin Mr P Taylor FRCP Edin Born: 30/12/1921 Died: 31/01/2018 Born: 15/04/1930 Died: 27/04/2018 Specialty: Radiology Specialty: Ophthalmology MB Edin 1944, MRCP Edin 1949, MD Edin 1953, DMRD MB Sheff 1953, MRCP Edin 1960 Edin 1955 Dr JC Voigt FRCP Edin Dr R L Lyon FRCP Edin Born: 12/07/1933 Died: 12/05/2018 Born: 05/09/1922 Died: 30/01/2018 Specialty: Obstetrics & Gynaecology Specialty: Geriatric Medicine BM Oxfd 1958, DObst 1960, MRCP Edin 1964 MB Edin 1945, MRCP Edin 1950, MD Edin 1960

JUNE 2018 VOLUME 48 ISSUE 2 JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH 191